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Academic Medicine:
doi: 10.1097/ACM.0b013e3180305fb1
Institutional Issues

Collision Course: The Privatization of Graduate Medical Education at One University

Klasko, Stephen K. MD, MBA; Ekarius, John C.

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Author Information

Dr. Klasko is vice president, Health Sciences, and dean, College of Medicine, University of South Florida, Tampa, Florida, and former dean of Drexel University College of Medicine, Philadelphia, Pennsylvania.

Mr. Ekarius is associate dean for external relations, Drexel University College of Medicine, Philadelphia, Pennsylvania.

Correspondence should be addressed to Dr. Klasko, University of South Florida, 12901 Bruce B Downs Blvd, MDC 2, Tampa, FL 33612-4799; telephone: (813) 974-0533; e-mail: (sklasko@health.usf.edu).

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Abstract

On December 18, 2003, Tenet Healthcare Corporation, an investor-owned hospital corporation, announced the closure of Medical College of Pennsylvania Hospital, a historic institution that was home to many of Drexel University College of Medicine’s (DUCOM’s) faculty, residents, and medical students. The authors summarize the steps that were taken and lessons learned to avoid a disruption in the education of over 200 residents. The authors highlight the response by the medical school; the concerns of the Accreditation Council for Graduate Medical Education (ACGME); the interaction between the Center for Medicare and Medicaid Services (CMS) and the ACGME; the importance of the designated institutional official (DIO) in a crisis situation; and the role of residents as students versus employees when their employer wishes to move or “trade” them to another institution. Through the lens of the DUCOM experience, the authors explore the legal, political, and educational conflicts that occur when an investor-owned company or private hospital employs residents but another entity holds moral and academic accountability for their future. Finally, the authors outline five lessons learned: (1) the important role the ACGME plays as the educational conscience of graduate medical education (GME), (2) the dramatically different roles that the ACGME and the CMS play in regulating and funding the national GME system, (3) the need for constant communication with the affected residents, (4) the important role that the DIO plays in GME, and (5) the need for medical school leaders to remain focused on their educational mission and responsibilities to young physicians.

Founded in 1850, the Female Medical College of Pennsylvania was the first American medical school devoted exclusively to the training of female physicians. Later renamed the Woman’s Medical College, the school operated in several hospitals in Philadelphia and moved to its final location in the East Falls section of the city in 1930. Facing financial difficulties, the school voted in 1969 to admit men and to raise the class size to accommodate their presence. As a result of this decision, the name was changed to the Medical College of Pennsylvania (MCP) Medical School and MCP Hospital (MCPH).

In 1987, MCP was acquired by the Allegheny Health, Education, and Research Foundation (Allegheny), a Pittsburgh-based hospital and physician practice organization that was pursuing an aggressive statewide growth strategy. In 1993, Allegheny acquired Philadelphia’s Hahnemann University Hospital, along with its affiliated medical school, nursing school, and school of public health. The two medical schools were merged into MCP–Hahnemann Medical School and made part of the Allegheny University of the Health Sciences in 1995.

By 1998, Allegheny had acquired 14 hospitals and over 300 Philadelphia-area primary care physician practices, along with nearly $1.3 billion in debt and losses of more than $1 million per day. Under the burden of this debt, Allegheny filed for bankruptcy. That year, Tenet Healthcare Corporation bought Allegheny’s Philadelphia assets from bankruptcy. Tenet acquired MCP and Hahnemann hospitals along with six others, all of Allegheny’s physician practices, and the Allegheny University of the Health Sciences. During the bankruptcy proceedings, civic leaders and state officials intervened to find an organization to take responsibility for the educational resources and personnel affected by the sale. Drexel University, a Philadelphia-based Carnegie Foundation–ranked research university, stepped forward to protect the educational programs and nearly 10,000 jobs of the hospitals and health sciences schools.

Drexel became a vital player in the restructuring because, as a for-profit company, Tenet was prohibited from owning the nonprofit educational assets of Allegheny. In light of this stipulation, ownership of the medical school, a nursing school, and the school of public health that Tenet had acquired were transferred to the newly formed Philadelphia Health and Education Corporation (PHEC). Drexel created PHEC to be a nonprofit entity managed by the university with an independent board of trustees comprising Drexel, Tenet, and Commonwealth of Pennsylvania appointees. In 2002, PHEC became a wholly owned subsidiary of Drexel, and the medical school was renamed the Drexel University College of Medicine (DUCOM). List 1 provides a full chronology of the MCP Hospital.

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Graduate Medical Education at MCPH

In 2003, Tenet, because of its large network of hospitals, was the largest supplier of accredited residency slots in the United States. The company maintained 215 Centers for Medicare and Medicaid Services (CMS)-funded training slots at MCPH and another 340 slots at Hahnemann. Between the two hospitals, the DUCOM graduate medical education (GME) program operated 35 residency and fellowship programs. Nationally, Tenet hospitals and their affiliates employed over 1,100 resident physicians.1

Although several opportunities existed for MCPH residents to complete rotations at non-Tenet hospitals, most of the MCPH residents conducted their rotations at MCPH and Hahnemann. Although Hahnemann was funded for 340 slots, the hospital, given its size, routinely accommodated residency rotations for nearly 420 physicians in training. After reorganization in 2001, the GME operation and resident experience moved from two separate hospital entities (MCPH and Hahnemann) to a more coordinated approach. After the move, GME for both hospitals was managed by a single designated institutional official (DIO) employed by Tenet. This individual and his staff were located at MCPH, but both programs were supervised as if they were one. This unification proved to be very valuable when administrators later decided to close MCPH and to merge the MCPH’s Medicare provider number residency positions with Hahnemann’s.

For DUCOM, MCPH represented about 40% of the school’s funded resident slots and provided a site for 25% of the actual resident training experience. Even though the resident physicians in the MCPH program were Tenet employees, DUCOM’s role as educational sponsor of the Accreditation Council for Graduate Medical Education (ACGME)-approved programs at MCPH was supervised by an associate dean of graduate education from the college. That individual worked continuously with the Tenet DIO and the school’s department chairs and residency program directors during the MCPH closure process to ensure the viability of training programs during the hospital phase-down, the identification and negotiation of alternative training opportunities for affected residents, and constant communication with the residents themselves.

The 215 resident slots that were supported by MCPH before the closure were a cornerstone asset of medical education for DUCOM and served as a vital link between teaching physicians and medical students. Even with DUCOM’s ability to secure clinical sites at other hospitals in the region for residents to complete rotations after the MCPH closure, DUCOM was dependent on maintaining the core complement of the 215 residents at MCPH by supporting the Tenet effort to relocate all of these MCPH Medicare provider number residency positions to Hahnemann. Failure to do so would have caused the school to lose its entire anesthesiology residency program, 60 department of medicine residents, and 15 radiology residency positions, in addition to the concomitant reductions in medical education opportunities.

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A Successful Resolution

From the moment Tenet announced the closure of MCPH on December 18, 2003, the most critical concern for DUCOM was to uphold its commitment to ensure that there would not be a disruption to the education of their more than 200 residents—in essence, it could have been the largest “orphaning” of residents in GME history. From the day after the announcement through the resolution of the crisis in July, 2004, the DUCOM dean’s office was in continuous contact with the ACGME (and almost 50 individual specialty residency review committees), the CMS, Tenet, and other hospitals on a weekly—and sometimes daily—basis to safeguard the displaced residency programs.

From late December 2003 to late February 2004, the DUCOM department chairs, program directors, and GME office were able to relocate almost 200 residents to other training sites as clinical activities at MCPH began to decrease and eventually cease. These efforts occurred simultaneously with legal efforts to petition CMS to allow DUCOM to reallocate the MCPH resident slots to other hospitals affiliated with DUCOM.

On February 20, 2004, Tenet agreed with public officials to keep MCPH open for three more months through June 30, 2004, while the Commonwealth of Pennsylvania and Tenet searched for a prospective hospital buyer. Although the plan to extend the hospital’s operation by an additional three months made sense from a public policy perspective (to continue the delivery of hospital services for the community), the time extension caused significant uncertainty for residents as they worked to resolve the status of their future training locations. Again, of concern from a GME perspective was that the welfare of the residents was not part of the political discussion and that DUCOM was not considered to be a necessary participant in the negotiations around extension of hospital services. Although DUCOM did not have political or business clout in this situation (because the medical school did not own the hospital), the residents’ futures were put on a tightrope controlled by factors that were totally independent of their educational needs. For example, many residents expecting to be “orphaned” had plans to transfer to other residency programs, which would clearly not be possible if MCPH remained open and they were still a “line item” in MCPH’s cost report. This tense public battle became a lightning rod for many who were concerned about the disconnect between the business of residency funding and the academic integrity of GME. It became an even greater potential disaster for international residents with HB1 visas whose immigration status was totally dependent on their work stability and paperwork. The reassignment of residents assigned to MCPH was complicated by the multiple factors involved in that process.

Clearly, when making decisions in the face of the MCPH closure, the educational value of the rotations to which residents would be reassigned was a primary factor in the decision matrix. But there were also patient care considerations. DUCOM was responsible for continuing the care of patients, who, in many cases, had no alternative sites of care delivery if their DUCOM faculty physicians were reassigned to or leaving for other venues. There were also political considerations because state officials had mandated that no major changes occur at MCPH without their knowledge. Because of this, the closure occurred slowly during a period of 15 months, such that the 55 residents who were physically present at MCPH in December 2003 were all moved to suitable alternative rotations by March 2005. Table 1 details the MCPH CMS residency positions and the ACGME-accredited residency rotation sites for December 2003 and March 2005. As Table 1 indicates, during this 15-month period, DUCOM lost no residents, even though no residents remained at MCPH, and DUCOM began two new hospital affiliations, one at Abington Memorial Hospital and one at Friends Psychiatric Hospital.

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By April 1, 2004, the situation started to stabilize through a series of related events:

▪ Temporary alternative rotation sites were found for 50 students and 100 residents.

▪ DUCOM and Tenet successfully negotiated an interim funding agreement, which ensured that Tenet would financially sustain the medical school during a transition, should MCPH be closed or purchased.

▪ DUCOM signed academic affiliation agreements with two new hospitals willing to serve as bases for both medical students and residents.

▪ A detailed MCPH purchase proposal was sent to government officials and Tenet for DUCOM’s acquisition and continued operation of MCPH.

DUCOM was one of three local groups that submitted bids on April 13, 2004, to purchase MCPH. DUCOM submitted a bid to safeguard its residency training programs and its other educational and clinical activities. Because DUCOM did not own or operate a hospital, the school’s administration entered a steep learning curve (and spent significant amounts on consulting) about potentially owning and operating a hospital that was in deficit. In March 2004, as DUCOM’s bid was being prepared, the ACGME agreed to forestall the next steps in the process of finding permanent replacement sites for the 215 residents training at MCPH. This agreement was subject to a May 15, 2004, deadline; after this date, the ACGME would resume its search for permanent replacement sites. The deadline came and went with no indication that DUCOM’s bid would be successful, but given the ACGME’s admonition about “selling” residents, school administrators hoped the ACGME would block any outright transfer of residents to other teaching hospitals. The most attractive alternative to the permanent relocation of residents was a plan that would allow the residents to remain with DUCOM through a merger of MCPH and Hahnemann’s Medicare provider numbers (residency cap numbers) that would take place before MCPH officially closed. A move from MCPH to Hahnemann, however, was unlikely to be approved, given the popular desire that the hospital remain on the MCPH site.

Finally, a decision was made. MCPH would be sold to a group led by a private practice cardiologist, who had little or no residency experience. Once again, the worries that residents would be treated as service workers in reimbursable slots began. The GME discussions among the new hospital administrators were based solely around determining the minimum number of residents that would be necessary to help the hospital run. DUCOM’s outside consultant commented that the negotiation around resident numbers would seem more appropriate if the resources in question were radiology equipment or gamma knives, rather than students who had entrusted their career development to DUCOM. Despite the fact that DUCOM was perceived as uncooperative throughout this process by public officials and community activists, the ACGME supported the school’s position. Once again, the medical school lived by its commitments to education and patient care. DUCOM took care of its patients and residents and allowed the politics and hospital sale to take care of itself.

In June 2004, the public controversy over the closure of MCPH wound down with the announcement that state and federal officials had brokered a compromise sale of the hospital to a new nonprofit group of physicians formed to continue operations. Tenet received CMS approval to merge the MCPH and Hahnemann University Hospital Medicare provider numbers (thereby merging the CMS residency slots), and DUCOM was assured that the full complement of both current and future residents would continue to receive appropriate training and supervision. The sale and asset transfer took place on September 1, 2004. DUCOM continued to provide some clinical services onsite and maintained a relatively few resident rotations in medicine and emergency medicine where appropriate. The hospital closed for good six months later in March 2005.

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Lessons Learned

During the six-month period from December 2003 through June 2004, there was an enormous public outcry over the closing of MCPH. The city council held hearings; city, state, and federal legislators and the governor became involved in the controversy; and numerous hospital and health care officials in the region were drawn into attempts to save the hospital. Throughout this period of uncertainty and public furor, as the individual futures of 215 resident physicians were being debated, there was also unease as to the future of DUCOM’s GME program, as all aspects of the dean’s office mobilized to handle the political, educational, financial, social, and strategic implications of the hospital’s closing. The following lessons from our experience at DUCOM helped us to realize a successful outcome during that period.

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Lesson 1: The ACGME is not just a regulatory agency; it functions as the educational conscience of GME

The ACGME had been involved with the dissolution of Allegheny in Philadelphia because of its effects on residency education and had been very supportive of DUCOM’s academic management of the residency programs during that dissolution. When Tenet’s public announcement of its intent to close MCPH implied that MCPH might be sold to a consortium of hospitals and that the MCPH residents were “part of the deal,” the ACGME provided what became the school’s only ammunition. In a letter dated May 12, 2004, the executive director of the ACGME wrote that the “ACGME will not tolerate any action which interrupts the educational flow of these residents. Residents cannot be sold or traded. Drexel University is the sponsoring institution and will be held to our standards of stewardship for those educational programs.” Until that time, DUCOM and its dean had hardly been consulted by the community activists or elected officials lobbying in Harrisburg, Pa, or Washington, DC, about the hospital’s future, despite its potential impact on the resident physicians. Those few simple statements from the ACGME ultimately provided the leverage that was needed to protect the residents.

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Lesson 2: Do not expect the ACGME and CMS to talk to each other

Once the political tug of war began over the fate of MCPH, the disconnect between the hospital’s funding source (the CMS) and its accrediting body (the ACGME) became apparent. There are two criteria for residency funding from CMS:

1. The institution must have a Medicare provider number for an acute hospital with residency numbers under the CMS-mandated cap.

2. The institution must have ACGME accreditation. Each residency that is funded has ACGME approval. ACGME accreditation, however, requires compliance with the institutional, common, and specialty program requirements.2

In every discussion with Tenet, federal officials, and representatives of the Commonwealth of Pennsylvania, the “sale” of MCPH was contingent on the flow of funds that followed the residents. The perception that the residents were part of the “deal” was in large part driven by federal and state public officials and potential hospital purchasers during their discussions with CMS. These discussions correctly indicated that the residents’ “funded slots” would move along to the new hospital owner and would not remain with the ACGME sponsoring institution, DUCOM. It became clear that the only recourse available to the educational sponsor of a troubled residency program is the ability of the ACGME to disaccredit or delay accreditation in a new hospital environment in situations where the ACGME feels that the residents’ educational continuity may be compromised. Thus, the ACGME provided a lifeline in a memo from its executive director that stated that the “ACGME views residents as students and not employees. When residents are treated as commodities to be traded for educational reimbursement, the ACGME acts by withdrawing accreditation. Medicare recognizes our work and reimbursements are disallowed if the educational program does not meet our standards.” By communicating the positions of the CMS and the ACGME together, that one sentence provided the impetus for the dealmakers to find a solution that included DUCOM and mandated continuity of training for the residents.

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Lesson 3: If you anticipate problems, and possibly a crisis, begin frequent communication with residents immediately

Fortunately, we had implemented an aggressive plan to improve morale among the DUCOM residents well before this crisis occurred. In a retreat cosponsored by Tenet and DUCOM in March 2003 (nine months before the closure of MCPH), we recognized that Tenet and DUCOM had very different priorities when it came to the maintenance and growth of GME. Before that retreat, the residents were viewed as employees by many of the financial operatives at Tenet and were subject to the same actions that would be taken by an investor-owned company that needed to reduce its expenses. The communication and clarity that resulted from that retreat started a series of events in which we communicated with the residents why they were “employed by Tenet” and sponsored by DUCOM. We also communicated to residents the analysis of the individual responsibilities of Tenet and DUCOM; these responsibilities were confirmed at that retreat. We confirmed that financial accountability and residency cap management resided with Tenet, but that education versus service management and academic excellence resided with DUCOM. Recruiting quality residents and maintaining loyalty after graduation was a joint responsibility. This process removed the mystery of GME operations and comprehensively identified all stakeholders and the role that each played in the GME process. Those communications before the crisis gave us the credibility to keep the residents concentrated on their work with the assurance that we would collaborate with Tenet in a manner that would be in the residents’ best academic interests.

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Lesson 4: Financial accountability, academic needs, and the history and excellence of your GME program are all crucial factors in a crisis; your DIO is a key to balancing those often competing demands

Once it was announced in December 2003 that the DUCOM residency complement might be cut by 40% in the middle of a recruiting period, department chairs and program directors began an emergency process of reassigning strategic priorities with this new reality in mind. Issues such as primary care versus specialty training, the history and excellence of different programs, and the impact of any change on medical student education needed to be considered within about a week of the announcement, because of the deadlines imposed by the National Residency Matching Program. The department chairs and program directors were faced with many difficult questions: How does one weigh the value of MCPH’s emergency medicine residency (the first in the country) against Hahnemann’s orthopedic residency, which had an almost equally long history? Should the school first try to maintain the number of residents in the liaison committee on medical education–mandated clerkship disciplines at MCPH, or should it try to spread the residency positions more broadly to satisfy competing hospital and academic needs? Thus began a series of meetings between academic leaders in the medical school and the university that consumed hundreds of hours and superseded all other considerations for the medical school for most of that academic year.

This urgent reshuffling of residency positions was complicated by a common battle that remains under the surface in most GME programs where the hospital entity is not part of the same system as the university entity: Where do we invest our residency resources, and where do we allocate, or reallocate, our cap numbers—in the most academically relevant specialties, or in those specialties that will have the greatest financial benefit to the hospital? This dichotomy quickly came to the fore when hospital and medical school leaders disagreed about who was responsible for making that decision. In the mind of the Hahnemann hospital CEO, the decision was his to make; after all, the residents were his “employees.” In the mind of the dean’s office, there was a clear academic accountability issue; after all, the residents were “students.” The crisis came into sharper focus when the revised residency numbers were drawn up. Predictably, DUCOM’s version “sacrificed” the hospital-based residencies in favor of the residencies and fellowships with more significant scholarly activity—fewer anesthesia, radiology, and trauma service-related residents, but no cuts in hematology–oncology or nephrology fellowships. The hospital CEO’s version was almost exactly the opposite—maintaining the service-related residencies was an important aspect of his proposed financial management of this crisis.

Fortunately, when the GME programs at MCPH and Hahnemann merged in 2001, DUCOM and Tenet had agreed that the newly combined GME program would be overseen by one Tenet-employed DIO. In this world, he was employed by Tenet, but he was held accountable by the sponsoring institution, DUCOM. This was not an easy job in the best of times, but it took on a critical role in the resolution of this issue. Our DIO, together with our associate dean for GME, was able to work with both hospital and medical school administrators to establish a matrix that considered the financial accountability, academic needs, and history and excellence of the GME program. Without the cooperation of the individuals involved and the appropriate balance of competing needs, the differences between the hospital’s and the school’s desires would have been irreconcilable. Rather than ignore these competing interests, we created a grid for each residency program that established the importance of the program to DUCOM’s undergraduate medical education curriculum, the history of the program, the academic excellence of that program on the basis of reputation and scholarly output, and the financial benefits of the program to the hospital CEO. The grid made decision making data-driven and minimized emotional output.

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Lesson 5: In times of stress, read your mission statement, remember why you’re in academic medicine, and stay focused

For an investor-owned company, the business mission is clear: maintain and enhance the company’s value to the shareholders. Although it would be naïve to argue that financial pressures have not placed similar pressures on not-for-profit academic institutions, the admonition that we often receive as deans to “remember our mission” is well stated. In this spirit, DUCOM’s management, from the board chair to the president to the dean’s office, stated three principles at the outset of this crisis that changed the course of the negotiations related to MCPH:

1. We would not participate in any discussion that hinted at using our residents as “bait” for a political solution to the MCPH problem.

2. We would continue to work with Tenet as a partner in finding a viable solution for the MCPH site to allow our residents to continue and finish their training as DUCOM residents.

3. We would not participate in meetings about the fate of our residents unless both their employer (Tenet) and the accrediting body (the ACGME) that would need to sanction any program changes were present.

These three components might seem self-evident, but they were an outgrowth of a pivotal meeting that brought to light the importance of explicitly outlining them as requirements of our decision-making process. In March 2004, a group consisting of representatives of other Philadelphia university hospitals and health systems met in Washington DC with a group of physicians led by a physician administrator with little GME experience, to “work with DUCOM” to determine what should be done with DUCOM’s residents once the hospital was sold. Notably absent from the meeting were the two most important players (other than DUCOM)—Tenet, the owner of the hospital and employer of the residents, was not invited, nor was the ACGME, which would need to accredit any site or residency change. Finding a political solution to what was inevitably a hospital finance and university accreditation issue was clearly not in anyone’s best interest. The meeting ended abruptly once the politicians, land developers, and hospital CEOs agreed with the academicians that GME and its principles were not as easily divided and negotiated as a traditional real estate transaction.

By following the five lessons described in this section, we were able to gain the confidence of the ACGME, of our faculty, and of our residents during a time that could have been devastating to a new medical school. In fact, in our opinion, adherence to these principles may have brought the medical school together in ways that would have been significantly more difficult had this crisis not occurred.

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Disaster Preparedness

Although DUCOM’s situation as a newly merged medical school in a partnership with an investor-owned hospital chain may seem unique, many factors of the resulting GME crisis may seem all too familiar to GME programs nationwide. For-profit hospital operators continue to act as employers of medical residents across the nation, and there continues to be a disconnect between residency programs’ funding sources and funding recipients (the CMS and hospitals) and between residency programs’ accrediting body and their academic entities (the ACGME and universities). Currently, for example, universities are experiencing increasing pressure from the ACGME and individual resident review committees (RRCs) to increase program directors’ protected time. Unfortunately, many of the academic organizations feeling that pressure do not control the flow of funds from the hospital entities. Residency numbers, physician supply, and service versus education continue to be hotly debated topics in GME programs across the country.

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Preparing a GME disaster kit

Even though our GME “disaster” may seem unique to DUCOM, other institutions can use our experience to increase their own awareness and preparedness, should a similar crisis occur. As with any disaster simulation scenario, GME program leaders should ask themselves, “Are we prepared?” The answer lies in a careful predisaster analysis of a GME program. Based on the DUCOM experience, the following are precautions that every dean and associate dean of GME should, in our opinion, include in their “disaster kits:”

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Thorough knowledge of CMS funding and ACGME accreditation issues, beyond the RRC site visits of individual programs.

If the hospital closed, what would happen? Which individuals would be involved? A working knowledge of the organizational structures of CMS and ACGME is a must.

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Familiarity with the “cap methodology” that the hospital employs.

Ideally, the academic entity and the hospital entity decide on those numbers together. If this collaboration is not stipulated in the affiliation agreement, it should be added at the next renewal.

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Awareness of the DIO.

Is he or she the kind of person that would act in the program’s best interest during a GME crisis? Does he or she have the requisite knowledge to handle such a crisis? Is it clear who employs the DIO and what the employer’s role is, vis-à-vis the hospital and the residency sponsor?

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A disaster drill with the hospital CEO.

In our experience, there were small skirmishes between officials from DUCOM and Tenet that could have predicted a discordance of GME- related missions. Having more of those discussions “before the rain came” would have been beneficial.

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Secondary affiliation agreements and residency out-rotation agreements.

Even if relationships between schools and primary teaching hospitals are tranquil right now, health care is a changing business. Administrators should recognize that if academic entities and affiliated hospitals are not owned by the same group, one or the other could be sold or could change its mission. Having the “safety valve” of secondary affiliation agreements and residency out-rotation agreements in times of crisis is always a good idea.

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An Association of American Medical Colleges project medical education or white coat program.

These programs allow federal and state legislators and staff to spend time with residents in the hospital to foster their awareness of GME. Discussing GME, its funding, its importance to the health of the community, and the necessity of preserving the sanctity of its academic nature before a crisis will keep GME issues in good stead should the political realities of a crisis take hold.

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After the Storm

We faced what was potentially the largest disaster in GME history, but our story has no villains. The officials at Tenet behaved as managers of an investor-owned company should, trying to protect their assets and make the right “business” decision. The CMS also acted according to protocol, following a complicated formula for resident funding that is dependent on numbers of bodies on cost reports. The politicians were doing their jobs as well by finding their way out of a politically messy hospital closing in a way that was least harmful to the community and to their political careers.

Our story has plenty of heroes, however. The ACGME, as always, went the extra mile to protect the residents. The doctors at MCPH, even in the face of such uncertainty, remained focused on patient care and residency education. A team of physicians that was newly appointed to head the DUCOM practice group dropped all revenue cycle and business development deliberations and fully focused on practice management and daily crisis management. Throughout the crisis, MCPH faced union walkouts, staff decreases, and morose morale, but the remaining doctors, residents, nurses, and staff came to work every day with the same passion for patient care and residency education that they had when MCPH was a functioning hospital.

It is precisely the absence of villains in our story that should raise concerns. Protecting GME and its independence, even when it is not threatened outright, should be an utmost priority across academic medicine. GME is the gateway between today’s students and our next generation of colleagues. How these individuals react to challenges and protect the academic medical system in the future will depend in large part on how academic and ethical decisions are handled in increasingly complex business environments today.

As with many health care dramas, ours came to an end with a whimper, not a bang. Because of the hard work of the doctors, nurses, and residents mentioned above, patient care was never compromised, even in a “war zone” atmosphere. These individuals ensured that the predominately underserved patient population continued to receive care, which, in turn allowed everyone involved to think carefully about the implications of considering residents the “ticket” to a quick, easy sale of the hospital. A private group purchased the hospital with the understanding that residents would remain at MCPH if it could be justified on the basis of quality of educational experience, not of service expediency. Tenet unloaded their unprofitable property in a manner that could satisfy their investors. The politicians could truthfully state that they had kept the doors of this hospital open. In the end, the private group who purchased MCPH could not successfully rebuild the hospital, but they had their day in the press and highlighted the difficulty of caring for an underserved population in an urban environment, an issue that stayed in the spotlight about as long as the group did.

After MCPH closed, the administration and faculty at DUCOM went back to what they did extremely well—teaching students, training residents, and making new scientific discoveries. And the dean’s office had newfound skills and knowledge in Securities and Exchange Commission regulations, CMS deliberations, state and federal politics, hospital management, mergers and acquisitions, and a greater knowledge of whom they could count on to protect the academic environment. For anyone involved in academic medicine and GME, the DUCOM–MCPH experience can serve as a case study and an argument for open education and discussion before a crisis looms.

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References

1 Accreditation Council for Graduate Medical Education. Graduate Medical Education Data Resource Book; Academic Year 2003–2004. Chicago, Ill: Accreditation Council for Graduate Medical Education; 2003.

2 American Medical Association. Graduate Medical Education Directory: 2006–2007. Chicago, Ill: American Medical Association; 2006:22.

© 2007 Association of American Medical Colleges

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